Liver and pancreatic islet transplant

Unusual double transplant combats two diseases

On Saturday, July 25, 1998, Mr. Patsy (Pasquale) Esposito, 65, of Orland Park, became the first person in the Midwest to receive a combined liver and pancreatic islet cell transplant.

Esposito, married and father of three, suffered from hepatitis C--a viral infection that destroyed his liver. He was also diabetic, requiring daily insulin shots to control his blood sugar.

Ordinarily, physicians would have performed only the life-saving liver transplant and continued to manage the patient's diabetes with insulin injections. However, transplant medicines--necessary to prevent rejection--make diabetes harder to control so that it requires far greater amounts of insulin treatment.

By transplanting the insulin-producing islet cells, however, Esposito's doctors hope they have given him the ability to produce insulin naturally so that his diabetes can be controlled without further medical treatment.

"Islet-cell transplantation has the potential to overcome diabetes," said Richard Thistlethwaite, MD, PhD, professor of surgery, chief of transplantation at the University of Chicago, and Esposito's surgeon. "But, because the recipients tend to mount a powerful immune response against these delicate cells, so far very few islet-cell transplants have succeeded."

More commonly, the whole pancreas--the organ in which insulin producing islets are found--is transplanted to treat diabetes. Adding a pancreas transplant to his liver transplant was thought to be too risky for Esposito because of his liver disease. "But by transplanting islets," added Dr. Thistlethwaite, "we avoided the extensive additional surgery necessary to transplant an entire pancreas."

The islet transplant is simple to perform. Islet cells, isolated from a donated pancreas, are injected into a vein that carries them into the liver. They then lodge within the liver and begin making insulin, regulating the patient's blood sugar.

However, getting the islets out of the donor pancreas without damaging them has daunted scientists for a long time. While Dr. Thistlethwaite was performing the liver transplant, in the operating room, Horatio Rilo, MD, director of the University of Chicago cell-transplant laboratory, meticulously extracted the pancreatic islets.

The doctors explained to Esposito in advance that they would call off the experimental islet transplant if they could not obtain adequate islets, but "the quality and purity of the islets from this donor were excellent," said Dr. Rilo. The physicians agreed to proceed.

For Esposito, the liver transplant--now a standard procedure--was of primary, life-saving importance. That operation began at 6 :00 a.m. on Saturday and was completed by noon. The experimental procedure followed. Dr. Rilo brought the islets to the operating room where Dr. Thistlethwaite administered them through an intravenous line leading into Esposito's new liver. The islet transplant itself took only about 15 minutes.

Four days after surgery, Esposito is listed as in fair condition and recovering well. His transplanted liver is functioning normally, and his new, liver-based islets are making insulin. He is now receiving about 10 units of insulin; before the transplant he injected 40 to 50 units of insulin each day.

How does it feel to the patient to be a pioneer? "Fine, if it works," said Esposito on the evening before his operation. "I've got nothing to lose and a lot to gain."

Because the islet cells and the transplanted liver come from the same donor, and the islet cells are lodged within the liver, monitoring and controlling the immune response is hoped to be easier in patients who receive a liver and islet transplant than when islets are transplanted alone. Only two other medical centers in the United States have performed the rare combined liver and islet cell transplants.